<%@ page language="java" contentType="text/html; charset=UTF-8"
    pageEncoding="UTF-8"%>
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>

	<head>
		<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">

		<meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no">
		<title>在线退保</title>
		<link href="../statics/css/bootstrap.min.css" rel="stylesheet" media="screen">
		<style type="text/css">
			input {
				border-style: none;
			}
			
			.aa {
				margin: 0px;
				padding: 0px;
				height: 100%;
				width: 100%;
				background: white;
			}
			
			.tablea {
				padding: 0px;
				margin: 0px;
				background: white;
			}
			
			.aac {
				padding: 0px;
				margin: 0px;
			}
			
			.submitab {
				background: rgb(253, 63, 96);
				border-style: none;
				border-radius: 0.5em;
				width: 23em;
				height: 3em;
				color: white;
				margin-top: 2em;
			}
			
			.submitaa {
				background: rgb(253, 63, 96);
				border-style: none;
				border-radius: 0.5em;
				width: 6em;
				height: 2em;
				color: white;
			}
		</style>
</head>

		<body>
			<div class="row aa">
				<div class="col-xs-12 aac">
					
					<div class="col-xs-12"><span style="font-size: 1em;">您正申请海安港过海保险退保,请填写以下信息:</span></div>
					<form action="">
						<table class="table tablea col-xs-12">

							<tr>
								<td class="col-xs-3">
									被保人姓名
								</td>
								<td class="col-xs-5">
									<input type="text" placeholder="请输入被保人姓名" />

								</td>
								<td class="col-xs-4">

								</td>

							</tr>

							<tr>
								<td class="col-xs-3">
									身份证号
								</td>
								<td class="col-xs-5">
									<input type="text " placeholder="请输入身份证号 ">

								</td>
								<td class="col-xs-4">

								</td>

							</tr>

							<tr>
								<td class="col-xs-3">
									保单号
								</td>

								<td><input type="text " placeholder="请输入保单号 "></td>

								<td class="col-xs-4">

								</td>

							</tr>

							<tr>
								<td class="col-xs-3">
									手机号
								</td>
								<td class="col-xs-5">
									<input type="text " placeholder="请输入手机号 ">

								</td>
								<td class="col-xs-4">

								</td>

							</tr>

							<div class="col-xs-12">
								<tr style="border-bottom: 1px solid gainsboro;">

									<td class="col-xs-4">验证码</td>
									<td class="col-xs-4">
										<input type="text " placeholder="请输入验证码 ">
									</td>
									<td class="col-xs-4">
										<input type="button" value="获取验证码 " class="submitaa">

									</td>

								</tr>
							</div>

						</table>

						<div class="col-xs-12 colae">
							<input class="submitab" type="submit" value="下一步" />
						</div>
					</form>

				</div>

			</div>

			<!---->
		</body>

</html>